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Original research
‘Power plays plus push’: experts’ insights into the development and implementation of active tuberculosis case-finding policies globally, a qualitative study
  1. Olivia Biermann1,
  2. Salla Atkins1,2,
  3. Knut Lönnroth1,
  4. Maxine Caws3,4,
  5. Kerri Viney1,5
  1. 1Global Public Health, Karolinska Institutet, Stockholm, Sweden
  2. 2New Social Research and Global Health and Development, Faculty of Social Sciences, Tampere University, Tampere, Finland
  3. 3Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
  4. 4Birat Nepal Medical Trust, Kathmandu, Nepal
  5. 5Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, New South Wales, Australia
  1. Correspondence to Olivia Biermann; olivia.biermann{at}


Objective To explore experts’ views on factors influencing national and global active case-finding (ACF) policy development and implementation, and the use of evidence in these processes.

Design This is an exploratory study based on semistructured expert interviews. Framework analysis was applied.

Participants The study involved a purposive sample of 39 experts from international, non-governmental and non-profit organisations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide.

Results This study highlighted the perceived need among experts for different types of evidence for ACF policy development and implementation, and for stakeholder engagement including researchers and policymakers to foster evidence use. Interviewees stressed the influence of government, donor and non-governmental stakeholders in ACF policy development. Such key stakeholders also influence ACF policy implementation, in addition to available systems and processes in a given health system, and implementers’ motivation and incentives. According to the interviewees, the World Health Organization (WHO) guidelines for systematic screening face the innate challenge of providing guidance to countries across the broad area of ACF in terms of target groups, settings and screening algorithms. The guidelines could be improved by focusing on what should be done rather than what can be done in ACF, and by providing howto examples. Leadership, integration into health systems and long-term financing are key for ACF to be sustainable.

Conclusions We provide new insights into ACF policy processes globally, particularly regarding facilitators for and barriers to ACF policy development, evidence need and use, and donor organisations’ influence. According to expert participants, national and global ACF policy development and implementation can be improved by broadening stakeholder engagement. Meanwhile, using diverse evidence to inform ACF policy development and implementation could mitigate the ‘power plays plus push’ that might otherwise disrupt and mislead these policy processes.

  • public health
  • tuberculosis
  • qualitative research
  • health policy

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors OB, KL, MC and KV conceived the study. OB developed the interview guides, which KL, MC and KV provided feedback on. OB conducted all interviews, coded them and developed an analytical framework. OB revised the coding and the analytical framework based on SA and KV’s input. OB charted the data into a framework matrix, which SA and KV provided feedback on. OB interpreted the data writing memos for each study theme, and discussed these with SA, KL and KV. All authors read and approved the final manuscript.

  • Funding This work was supported by the EU-Horizon 2020-funded IMPACT-TB project (grant 733174), from which OB, KL and MC are partly funded. KV is supported by a Sidney Sax Early Career Fellowship from the Australian National Health and Medical Research Council (GNT1121611).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This study has been approved by the Swedish Ethical Review Authority (Regionala Etikprövningsnämnden) in Stockholm (reference: 2017/2281-31/2). Participants received information about the study and provided written informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. The data generated and/or analysed in the study are not publicly available due to participant anonymity.

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